2015年3月进修视频2课件mechanical ventilation of chronic obstructive pulmonary disease

1、COPD患者的机械通气北京协和医院杜斌AECOPD的病理生理Mechanical Ventilation of COPD / Asthma | Bin DuAirway inflammationAirway narrowing & obstructionFrictional WOBShortened muscles, curvatureAir trappingAuto-PEEPVEmuscle strengthVtVAPaCO2pHPaO2Elastic WOBVCO2SteroidsAbxBDsMV?IPAPMV?IPAPMVPEEPAECOPD的病理生理机制呼气气流的驱动压降低肺弹性回缩力

2、不明原因的异常下降呼气相吸气肌肉活动导致胸壁向外的回缩力异常升高气道阻力显著升高气道半径缩小呼气相声门裂狭窄后果肺过度充盈（FRC增加到正常值的2倍）呼吸系统时间常数增加Mechanical Ventilation of COPD / Asthma | Bin DuPeress L, Sybrecht G, Macklem PT. The mechanism of increase in total lung capacity during acute asthma. Am J Med 1976; 61: 165-169McCarthy DS, Sigurdson M. Lung elasti

3、c recoil and reduced airflow in clinically stable asthma. Thorax 1980; 35: 298-302Colebatch HJ, Finucane KE, Smith MM. Pulmonary conductance and elastic recoil relationships in asthma and emphysema. J Appl Physiol 1973; 34: 143-153Cormier Y, Lecours R, Legris C. Mechanisms of hyperinflation in asthm

4、a. Eur Respir J 1990; 3:619-624Collett PW, Brancatisano T, Engel LA. Changes in the glottic aperture during bronchial asthma. Am Rev Respir Dis 1983; 128: 719-723Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto-PEEP ef

5、fect. Am Rev Respir Dis 1982; 126: 166-170Ranieri VM, Grasso S, Fiore T, Giuliani R. Auto-positive end-expiratory pressure and dynamic hyperinflation. Clin Chest Med 1996; 17: 379-394时间常数()Tau呼气容积残余容积00%100%163.0%37.0%395.0%5.0%599.9%0.1%健康成人2 x 0.10 = 0.20”术后气管插管成人5 x 0.06 = 0.30”COPD成人15 x 0.06 =

6、0.90”ARDS成人8 x 0.03 = 0.24”ARDS患儿5 x 0.01 = 0.05”Mechanical Ventilation of COPD / Asthma | Bin Du动态过度充盈的发病机制Mechanical Ventilation of COPD / Asthma | Bin DuinspexpTimeVTVEETidal volumeTrapped gasLung VolumeFRCObstructed LungsNormal Stiff LungsLevy BD, Kitch B, Fanta CH. Medical and ventilatory manag

7、ement of status asthmaticus. Intensive Care Med 1998, 24: 105-117.VEI = VT + VEECOPD机械通气适应证呼吸肌疲劳且濒临呼吸停止尽管进行充分的保守治疗, PaCO2仍进行性升高劳累和(或)高碳酸血症导致意识状态恶化高浓度吸氧治疗无效的低氧血症痰液清除障碍导致病情恶化呼吸骤停Mechanical Ventilation of COPD / Asthma | Bin DuCOPD机械通气的目的缓解呼吸肌疲劳改善气体交换，使其恢复至基础水平防止动态过度充盈和（或）auto-PEEP加重，以免导致循环功能衰竭Mechanic

8、al Ventilation of COPD / Asthma | Bin DuCOPD机械通气策略控制性低通气(controlled hypoventilation)最先由Darioli和Perret于1984年提出不同于允许性高碳酸血症(permissive hypercapnia)严重气流梗阻患者难以纠正PaCO2增加分钟通气量可加重过度充盈及死腔纠正高碳酸血症效果有限Mechanical Ventilation of COPD / Asthma | Bin DuLeatherman JW. Mechanical ventilation for severe asthma. Respir

9、 Care 2007; 52: 1460-1461确定COPD基础气体交换水平ABG考虑思路是否需要处理？平时PaCO2如何？既往结果的提示如果没有既往结果Mechanical Ventilation of COPD / Asthma | Bin DupH7.202PaCO289.2 mmHgPaO258.9 mmHgSaO291.9%HCO337.9 mmol/LBE11.9 mmol/LLA2.2 mmol/L确定COPD基础气体交换水平ABG考虑思路如何根据急性发作时ABG确定平时的PaCO2？pH PaCO2 / HCO3pH 40/24 PaCO2 / 37.9Mechanical

10、Ventilation of COPD / Asthma | Bin DupH7.202PaCO289.2 mmHgPaO258.9 mmHgSaO291.9%HCO337.9 mmol/LBE11.9 mmol/LLA2.2 mmol/L确定COPD气体交换目标以PaCO2不低于基础水平为目标e.g. PaCO2 68 mmHg, pH 7.18 MinVent 9 lpm允许范围PaCO2 7.20Mechanical Ventilation of COPD / Asthma | Bin DuLeatherman JW, McArthur C, Shapiro RS. Effect of

11、prolongation of expiratory time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med 2004; 32: 1542-1545PaCO2的影响因素VCO2做功躁动癫痫WOB代谢发热CHOT4VAVERRVtVd (不伴VE)Mechanical Ventilation of COPD / Asthma | Bin DuPaCO2 VCO2MinVent (1 Vd/Vt)死腔增加时不应盲目增加分钟通气量Mechanical Ve

12、ntilation of COPD / Asthma | Bin DuVtPalv生理死腔MinVentPEEPITPPaO2PvO2CO休克COPD机械通气：减轻动态过度充盈降低潮气量减慢呼吸频率降低呼气阻力缩短吸气时间增加吸气流量使用硬质管路降低CO2产量Mechanical Ventilation of COPD / Asthma | Bin DuStather DR, Stewart TE. Mechanical ventilation in severe asthma. Crit Care 2005; 9: 581-587降低分钟通气量是避免气体闭陷最有效的方法AECOPD/哮喘机械

13、通气初始设置呼吸参数设置模式VCV分钟通气量 10 lpm潮气量6 10 ml/kg PBW呼吸频率10 14 bpm平台压 90%Mechanical Ventilation of COPD / Asthma | Bin DuOddo M, Feihl F, Schaller M, et al. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med 2006; 32: 501-510COPD机械通气模式的选择Mechanical Ventilatio

14、n of COPD / Asthma | Bin DuOddo M, Feihl F, Schaller M, et al. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med 2006; 32: 501-510控制 vs. 辅助深度镇静 +/- 肌松以避免人机不同步定容 vs. 定压气道阻力和autoPEEP很高时，压力控制可能导致肺泡低通气气道梗阻迅速缓解时，压力控制可能导致呼吸性碱中毒定容通气没有上述风险，但需密切监测气道压力MinVent恒定

15、时的潮气量Mechanical Ventilation of COPD / Asthma | Bin DuTuxen DV, Lane S. The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation inmechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis 1987; 136: 872-879COPD吸气气流波形Mechanical Ventilation o

16、f COPD / Asthma | Bin DuYang SC, Yang SP. Effects of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COPD patients during mechanical ventilation. Chest 2002; 122: 2096-2104COPD吸气气流波形吸气气流波形呼吸机参数恒定气流1正弦波减速气流恒定气流2Vt, ml562 67558 65566 59571 72RR, bpm18.2 1.718.

17、6 1.418.4 1.918.5 1.3MV, lpm10.4 1.610.3 1.510.6 1.610.7 1.8Ti/Ttot0.29 0.040.28 0.030.29 0.040.28 0.03平均吸气流量, lpm38 537 739 738 6Mechanical Ventilation of COPD / Asthma | Bin DuYang SC, Yang SP. Effects of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COP

18、D patients during mechanical ventilation. Chest 2002; 122: 2096-2104COPD吸气气流波形吸气气流波形呼吸力学参数恒定气流1正弦波减速气流恒定气流2PIP, cmH2O47.1 11.547.8 10.839.5 9.746.6 11.0Paw, cmH2O7.6 4.27.2 4.88.4 4.58.4 3.9Pplat, cmH2O20.2 9.119.6 10.618.9 8.821.4 10.4Vd/Vt, %58.4 5.254.5 6.348.6 5.557.6 4.9Cst, ml/cmH2O35.3 8.935.

19、8 11.236.6 9.337.2 9.7Mechanical Ventilation of COPD / Asthma | Bin DuYang SC, Yang SP. Effects of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COPD patients during mechanical ventilation. Chest 2002; 122: 2096-2104COPD吸气气流波形吸气气流波形恒定气流1正弦波减速气流恒定气流2pH7.44

20、0.047.44 0.077.43 0.067.44 0.04PaO2/FiO2, mmHg236 73231 65223 70227 67PaCO2, mmHg45 1045 1037 946 12A-aDO2, mmHg133.1 36.5136.4 34.2156.3 33.7134.4 35.3HR, bpm106.1 18.1108.3 20.2105.3 18.9109.9 20.5MAP, mmHg92 2388 1888 2190 19Mechanical Ventilation of COPD / Asthma | Bin DuYang SC, Yang SP. Effect

21、s of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COPD patients during mechanical ventilation. Chest 2002; 122: 2096-2104COPD吸气气流波形吸气气流波形参数恒定气流1正弦波减速气流恒定气流2WOB, J/L0.92 0.160.88 0.180.75 0.150.92 0.18Raw, cmH2O/L/s12.6 3.112.4 3.611.2 2.412.5 3.3VO2, ml/m

22、in384 53389 60377 49382 52VCO2, ml/min274 52280 47273 56276 55症状评分54.5 13.458.6 11.942.7 12.356.1 12.8Mechanical Ventilation of COPD / Asthma | Bin DuYang SC, Yang SP. Effects of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COPD patients during mechanical

23、 ventilation. Chest 2002; 122: 2096-2104COPD吸气气流波形Mechanical Ventilation of COPD / Asthma | Bin DuYang SC, Yang SP. Effects of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COPD patients during mechanical ventilation. Chest 2002; 122: 2096-2104COPD患者机械通气的最

24、佳吸气气流为减速气流Vt, TI和Pplat相似的情况下，PIP更低正常肺泡过度牵张的风险减小高压报警减少，从而确保潮气量通过选择适宜的吸气气流，有可能改善患者的通气Vt恒定时的呼吸频率Mechanical Ventilation of COPD / Asthma | Bin DuTuxen DV, Lane S. The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation inmechanical ventilation of patients with severe air-

25、flow obstruction. Am Rev Respir Dis 1987; 136: 872-879延长TE：Flow vs. RRVtRRFlowTtotTITETE0.515304.001.003.000.515604.000.503.500.500.514304.301.003.300.30Mechanical Ventilation of COPD / Asthma | Bin DuVtRRFlowTtotTITETE0.515604.000.503.500.5151204.000.253.750.250.514604.300.503.800.30Oddo M, Feihl F

26、, Schaller M, et al. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med 2006; 32: 501-510延长TE的有效方法取决于吸气流量基础值VE 10 lpm且TE 4”时延长TE的作用Mechanical Ventilation of COPD / Asthma | Bin DuLeatherman JW, McArthur C, Shapiro RS. Effect of prolongation of expirato

27、ry time on dynamic hyperinflation in mechanically ventilated patients with severe asthma. Crit Care Med 2004; 32: 1542-1545COPD机械通气：外源性PEEP6名重度气道梗阻患者PEEP 5 15 cmH2OVEI, FRC, Pplat相应升高Peso, CVP升高，CO和MAP降低Mechanical Ventilation of COPD / Asthma | Bin DuTuxen DV. Detrimental effects of positive end-exp

28、iratory pressure during controlled mechanical ventilation of patients with severe airflow obstruction. Am Rev Respir Dis 1989; 140: 5-9COPD机械通气：外源性PEEPMechanical Ventilation of COPD / Asthma | Bin DuCaramez MP, Borges JB, Tucci MR, et al. Paradoxical responses to positive end-expiratory pressure in

29、patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD机械通气：外源性PEEPMechanical Ventilation of COPD / Asthma | Bin DuCaramez MP, Borges JB, Tucci MR, et al. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during

30、 controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD机械通气：外源性PEEPMechanical Ventilation of COPD / Asthma | Bin DuCaramez MP, Borges JB, Tucci MR, et al. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2

31、005; 33: 1519-1528COPD机械通气：外源性PEEPMechanical Ventilation of COPD / Asthma | Bin DuCaramez MP, Borges JB, Tucci MR, et al. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD机械通气：外源性PEEPMecha

32、nical Ventilation of COPD / Asthma | Bin DuCaramez MP, Borges JB, Tucci MR, et al. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528COPD机械通气：外源性PEEPMechanical Ventilation of COPD / Asthma | Bi

33、n DuCaramez MP, Borges JB, Tucci MR, et al. Paradoxical responses to positive end-expiratory pressure in patients with airway obstruction during controlled ventilation Crit Care Med 2005; 33: 1519-1528对于气道梗阻的部分患者而言, 应用控制通气过程中, 设置外源性PEEP能够缓解过度充盈基础疾病, 机械力学指标或呼吸机设置均无法预测上述结果逐渐增加PEEP并观察平台压力改变, 是减少副作用的合理方

34、法COPD机械通气：外源性PEEPMechanical Ventilation of COPD / Asthma | Bin DuGuerin C, Milic-Emili J, Fournier G: Effect of PEEP on work of breathing in mechanically ventilated COPD patients. Intensive Care Med 2000； 26: 1207-1214.对于COPD患者 40%的吸气肌力用于克服autoPEEP外源性PEEP能够减少触发吸气所需的吸气肌力，并改善人机协调性COPD机械通气：外源性PEEPAECOP

35、D控制通气过程中不宜应用外源性PEEP一旦自主呼吸恢复，应使用低水平PEEP保证患者舒适不超过autoPEEP降低触发功Mechanical Ventilation of COPD / Asthma | Bin DuAECOPD/哮喘机械通气初始设置呼吸参数设置模式VCV分钟通气量 10 lpm潮气量6 10 ml/kg PBW呼吸频率10 14 bpm平台压 90%Mechanical Ventilation of COPD / Asthma | Bin DuOddo M, Feihl F, Schaller M, et al. Management of mechanical ventil

36、ation in acute severe asthma: practical aspects. Intensive Care Med 2006; 32: 501-510COPD自主呼吸时呼气触发灵敏度Mechanical Ventilation of COPD / Asthma | Bin DuTassaux D, Gainnier M, Battisti A, et al. Impact of expiratory trigger setting on delayed cycling and inspiratory muscle workload. Am J Respir Crit Care Med 2005; 172: 1283-1289COPD自主呼吸时呼气触发灵敏度Mechanical Ventilation of COPD / Asthma | Bin DuTassaux D, Gainnier M, Battisti A, et al. Impact of expiratory trigger setting on delayed cycling and inspiratory muscle workload. Am J Respir Crit Care Med 2005; 172: 1283-1289COPD自主呼吸时呼气触发灵敏度Mecha